Empirical therapy for empyema complicating an indwelling pleural catheter in adults

For antibiotic management of adults with empyema associated with indwelling pleural catheters, use:

flucloxacillin 2 g intravenously, 6-hourly. For adults with septic shock or requiring intensive care support, use a 4-hourly dosing interval. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment. See advice on modification and duration of therapy flucloxacillin flucloxacillin flucloxacillin

PLUS if the adult has septic shock or is at increased risk of MRSA

vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

For adults who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, replace flucloxacillin in the above regimen with:

cefazolin 2 g intravenously, 8-hourly. For adults with septic shock or requiring intensive care support, use a 6-hourly dosing interval. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. See advice on modification and duration of therapy. cefazolin cefazolin cefazolin

For adults who have had a severe immediate¹ hypersensitivity reaction to a penicillin, the cefazolin-based regimen (as above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For adults who have had a severe immediate¹ hypersensitivity reaction to a penicillin in whom the cefazolin-based regimen is not used, or for adults who have had a severe delayed² hypersensitivity reaction to a penicillin, replace flucloxacillin in the above regimen with:

moxifloxacin 400 mg intravenously, daily. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment. See advice on modification and duration of therapy. moxifloxacin moxifloxacin moxifloxacin

Pharmacokinetics may be altered in patients who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure in adults with empyema complicating an indwelling pleural catheter who have septic shock or require intensive care support, modified dosages of flucloxacillin and cefazolin are recommended. Once the critical illness has resolved, consider switching to the standard dosage.

¹ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

² Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return